The role of sociodemographic, psychosocial, and behavioral factors in the use of preventive healthcare services in children and adolescents: results of the KiGGS Wave 2 study.

BACKGROUND: In Germany, various preventive services are offered to children and adolescents. These include regular standardized examinations (so called U/J examinations) and several vaccinations. Although strongly recommended, most of them are not mandatory. Our aim is to identify factors associated with the use of U/J examinations and vaccination against diphtheria, hepatitis B, Hib, pertussis, polio, and tetanus. While previous research has focused on sociodemographic factors, we also include socioeconomic, behavioral, and psychosocial factors. METHODS: We analyzed cross-sectional data from 15,023 participants (aged 0-17 years) of the nationwide representative KiGGS Wave 2 Survey. Participation in U/J examinations was assessed using a questionnaire, filled out by participants and/or their parents. Information on vaccination status was drawn from the participants' vaccination booklets. To identify relevant determinants for the use of preventive examinations and vaccinations, unadjusted and adjusted logistic regression models were employed with up to 16 different independent variables. RESULTS: Various independent variables showed an association with the use of preventive services. Higher socioeconomic status, absence of migration background, and lower household size were associated with significantly higher utilization of U examinations. Parents' marital status, area of residence, behavioral and psychosocial factors yielded insignificant results for most U/J examinations. Higher vaccination rates were found for children with no migration background, with residence in eastern Germany, lower household size, and with married parents. CONCLUSION: This study attempted to depict the influence of sociodemographic, psychosocial, and behavioral factors on the use of several preventive services. Our results indicate that predominantly sociodemographic variables influence the use of preventive services. Further efforts should be made to investigate the interplay of different determinants of healthcare use in children and adolescents.

Health inequalities among young workers: the mediating role of working conditions and company characteristics.

OBJECTIVE: Few studies have investigated health inequalities among young workers. The objectives of this study are to assess the extent of health inequalities in a sample of job starters and to explore the contribution of job demands and organisational factors. METHODS: We analyze data from the BIBB/BAuA Youth Employment Survey 2012. The cross-sectional survey includes a representative sample of 3214 German employees, apprentices, and trainees aged 15-24 years. Individuals were grouped by their years of schooling into low (< 12 years) and high levels of education (≥ 12 years). Regression analysis estimated the link between education and four health outcomes: self-rated health, number of health events, musculoskeletal symptoms, and mental health problems over the last 12 months. Counterfactual mediation analysis tested for indirect effects of education via working conditions (i.e., physical and psychosocial job demands) and company characteristics (i.e., company size, health prevention measures, financial situation, downsizing). All analyses were adjusted for age, sex, nationality, region, working hours, job tenure, employment relationship, and economic sector. RESULTS: Highly educated workers reported better self-rated health (b = 0.24, 95% CI 0.18-0.31) and lower numbers of health events (Rate Ratio (RR) = 0.74, 95% CI 0.67-0.82), musculoskeletal symptoms (RR = 0.73, 95% CI 0.66-0.80) and mental health problems (RR = 0.84, 95% CI 0.76-0.93). Total job demands explained between 21.6% and 87.2% of the educational differences (depending on health outcome). Unfavourable company characteristics were associated with worse health, but showed no or only small mediation effects. CONCLUSIONS: Health inequalities are already present at the early working career due to socio-economically stratified working hazards. To enhance prevention measures that aim at reducing inequalities in workplace health, we propose shifting attention towards earlier stages of life.

Young people's health and well-being during the school-to-work transition: a prospective cohort study comparing post-secondary pathways.

BACKGROUND: At the end of secondary education, young people can either start vocational training, enter university, directly transition to employment or become unemployed. Research assumes that post-secondary pathways have immediate and/or long-term impacts on health and well-being, but empirical investigations on this are scarce and restricted to few countries. Therefore, this study traced the development of health and well-being throughout the highly institutionalised school-to-work transition (STWT) in Germany. METHODS: We used longitudinal data of the National Educational Panel Study (NEPS), a representative sample of 11,098 school-leavers (50.5% girls) repeatedly interviewed between 2011 and 2020. We estimated the effect of post-secondary transitions on self-rated health and subjective well-being by applying fixed-effects (FE) regression, eliminating bias resulting from time-constant confounding and self-selection into different pathways. A multiple-sample strategy was used to account for the increasing diversity of STWTs patterns. Models were controlled for age, as well as household and residential changes to minimise temporal heterogeneity. RESULTS: Findings indicate that leaving school was good for health and well-being. Compared with participants who did not find a training position after school, direct transitions to vocational training or university were linked to higher absolute levels of health and well-being, but also to a lower relative decline over time. Furthermore, upward transitions (e.g. to programs leading to better education or from unemployment to employment) were associated with improvements in health and well-being, while downward transitions were followed by deteriorations. CONCLUSION: Findings suggest that school-leave is a sensitive period and that post-secondary pathways provide young people with different abilities to maintain health and well-being. Youth health interventions might benefit when setting a stronger focus on unsuccessful school-leavers.

Moderating or mediating effects of family characteristics on socioeconomic inequalities in child health in high-income countries - a scoping review.

BACKGROUND: By explaining the development of health inequalities, eco-social theories highlight the importance of social environments that children are embedded in. The most important environment during early childhood is the family, as it profoundly influences children's health through various characteristics. These include family processes, family structure/size, and living conditions, and are closely linked to the socioeconomic position (SEP) of the family. Although it is known that the SEP contributes to health inequalities in early childhood, the effects of family characteristics on health inequalities remain unclear. The objective of this scoping review is to synthesise existing research on the mediating and moderating effects of family characteristics on socioeconomic health inequalities (HI) during early childhood in high-income countries. METHODS: This review followed the methodology of "Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews". To identify German and English scientific peer-reviewed literature published from January 1st, 2000, to December 19th, 2019, the following search term blocks were linked with the logical operator "AND": (1) family structure/size, processes, living conditions, (2) inequalities, disparities, diversities, (3) income, education, occupation, (4) health and (5) young children. The search covered the electronic databases PubMed, PsycINFO, and Scopus. RESULTS: The search yielded 7,089 records. After title/abstract and full-text screening, only ten peer-reviewed articles were included in the synthesis, which analysed the effects of family characteristics on HI in early childhood. Family processes (i.e., rules /descriptive norms, stress, parental screen time, parent-child conflicts) are identified to have mediating or moderating effects. While families' living conditions (i.e., TVs in children's bedrooms) are suggested as mediating factors, family structure/size (i.e., single parenthood, number of children in the household) appear to moderate health inequalities. CONCLUSION: Family characteristics contribute to health inequalities in early childhood. The results provide overall support of models of family stress and family investment. However, knowledge gaps remain regarding the role of family health literacy, regarding a wide range of children's health outcomes (e.g., oral health, inflammation parameters, weight, and height), and the development of health inequalities over the life course starting at birth.

Depressive symptoms in higher education students during the COVID-19 pandemic: the role of containment measures.

BACKGROUND: Students are a vulnerable group for the indirect impact of the COVID-19 pandemic, particularly their mental health. This paper examined the cross-national variation in students' depressive symptoms and whether this can be related to the various protective measures implemented in response to the initial stage of the COVID-19 outbreak. METHODS: Student data stem from the COVID-19 International Student Well-being Study, covering 26 countries during the first wave of the COVID-19 pandemic. Country-level data on government responses to the COVID-19 pandemic were retrieved from the Oxford COVID-19 Tracker. Multilevel analyses were performed to estimate the impact of the containment and economic support measures on students' depressive symptoms (n = 78 312). RESULTS: School and workplace closures, and stay-at-home restrictions were positively related to students' depressive symptoms during the COVID-19 pandemic, while none of the economic support measures significantly related to depressive symptoms. Countries' scores on the index of these containment measures explained 1.5% of the cross-national variation in students' depressive symptoms (5.3%). This containment index's effect was stable, even when controlling for the economic support index, students' characteristics, and countries' epidemiological context and economic conditions. CONCLUSIONS: Our findings raise concerns about the potential adverse effects of existing containment measures (especially the closure of schools and workplaces and stay-at-home restrictions) on students' mental health.

Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy.

BACKGROUND: Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS: The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS: The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS: To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

Intake of dietary fats and fatty acids and the incidence of type 2 diabetes: A systematic review and dose-response meta-analysis of prospective observational studies.

BACKGROUND: The role of fat quantity and quality in type 2 diabetes (T2D) prevention is controversial. Thus, this systematic review and meta-analysis aimed to investigate the associations between intake of dietary fat and fatty acids and T2D, and to evaluate the certainty of evidence. METHODS AND FINDINGS: We systematically searched PubMed and Web of Science through 28 October 2019 for prospective observational studies in adults on the associations between intake of dietary fat and fatty acids and T2D incidence. The systematic literature search and data extraction were conducted independently by 2 researchers. We conducted linear and nonlinear random effects dose-response meta-analyses, calculated summary relative risks (SRRs) with their corresponding 95% confidence intervals (95% CIs), and assessed the certainty of evidence. In total, 15,070 publications were identified in the literature search after the removal of duplicates. Out of the 180 articles screened in full text, 23 studies (19 cohorts) met our inclusion criteria, with 11 studies (6 cohorts) conducted in the US, 7 studies (7 cohorts) in Europe, 4 studies (5 cohorts) in Asia, and 1 study (1 cohort) in Australia. We mainly observed no or weak linear associations between dietary fats and fatty acids and T2D incidence. In nonlinear dose-response meta-analyses, the protective association for vegetable fat and T2D was steeper at lower levels up to 13 g/d (SRR [95% CI]: 0.81 [0.76; 0.88], pnonlinearity = 0.012, n = 5 studies) than at higher levels. Saturated fatty acids showed an apparent protective association above intakes around 17 g/d with T2D (SRR [95% CI]: 0.95 [0.90; 1.00], pnonlinearity = 0.028, n = 11). There was a nonsignificant association of a decrease in T2D incidence for polyunsaturated fatty acid intakes up to 5 g/d (SRR [95% CI]: 0.96 [0.91; 1.01], pnonlinearity = 0.023, n = 8), and for alpha-linolenic acid consumption up to 560 mg/d (SRR [95% CI]: 0.95 [0.90; 1.00], pnonlinearity = 0.014, n = 11), after which the curve rose slightly, remaining close to no association. The association for long-chain omega-3 fatty acids and T2D was approximately linear for intakes up to 270 mg/d (SRR [95% CI]: 1.10 [1.06; 1.15], pnonlinearity < 0.001, n = 16), with a flattening curve thereafter. Certainty of evidence was very low to moderate. Limitations of the study are the high unexplained inconsistency between studies, the measurement of intake of dietary fats and fatty acids via self-report on a food group level, which is likely to lead to measurement errors, and the possible influence of unmeasured confounders on the findings. CONCLUSIONS: There was no association between total fat intake and the incidence of T2D. However, for specific fats and fatty acids, dose-response curves provided insights for significant associations with T2D. In particular, a high intake of vegetable fat was inversely associated with T2D incidence. Thus, a diet including vegetable fat rather than animal fat might be beneficial regarding T2D prevention.

Requirements for (web-based) physical activity interventions targeting adults above the age of 65 years - qualitative results regarding acceptance and needs of participants and non-participants.

BACKGROUND: It remains unclear how physical activity (PA) interventions need to be designed to reach older adults and to be widely accepted in this target group. The aim of this study was to assess the acceptance of a web-based PA program, including individual intervention components as well as relevant contextual factors, and to specify requirements for future interventions. METHODS: Two hundred sixty-six participants of a PA intervention completed a questionnaire covering individual program components (content, structure, and context). Further, 25 episodic guided interviews focusing on reasons for (non-) participation were conducted with 8 participants and 17 non-participants. Following qualitative content analysis, different requirements were identified and organized based on the social-ecological model, resulting in a profile of requirements. RESULTS: Based on the participants' and non-participants' statements, six different levels of requirements affecting acceptance of and successful participation in a web-based PA intervention were identified. The individual fit was influenced by an interaction of different factors at the intrapersonal, sociocultural, content, spatial, digital and organizational levels. Several age- and gender-specific requirements were noted in the interviewed older adults. Men and women, as well as younger (< 70 years) and older (≥70 years) adults differed in terms of perceived enjoyment and benefits of socializing while exercising together, the time expenditure perceived to be acceptable, previous digital skills, as well as in perceptions that ambience and accessibility of exercise facilities in the neighborhood were important. CONCLUSIONS: To motivate older adults to engage in PA and address different needs in terms of life circumstances and quality of life as well as differences in technical affinity, different requirement profiles should be included in the process of intervention development and implementation. Participatory development loops and modular offer formats are recommended for this.

Impact of the intervention program "JolinchenKids - fit and healthy in daycare" on energy balance related-behaviors: results of a cluster controlled trial.

BACKGROUND: The purpose of this study was to evaluate the multi-component health promotion program, JolinchenKids - fit and healthy in daycare, designed to promote physical activity (PA), healthy eating, and mental wellbeing among 3- to 6-year-old preschoolers. METHODS: For this cluster controlled trial, 62 daycare facilities (DFs) from thirteen different federal states in Germany were recruited (31 intervention, 31 control DFs). Outcome measures were children's habitual PA, fruits and vegetable consumption, consumption of unsweetened beverages and snacks with parents as raters. Study nurses assessed children's body composition and motor skills. Data was collected at baseline and 12 months later. To track adherence to the implementation of intervention modules at individual DF groups, an implementation calendar was used from baseline to follow-up. Linear mixed models were used to investigate effects for survey, group and their interaction at the individual level while accounting for clustering. RESULTS: Samples of 831 (baseline) and 641 (follow-up) children aged 4.3 ± 0.8 and 5.2 ± 0.8 years were analysed. More than half of the intervention DFs chose the nutrition or PA module for the first year of implementation while an implementation level of > 50% was only achieved in less than a third. A significant intervention effect (survey × group interaction) was found for the standing long jump favouring children at intervention DFs (ß = 3.08; 95% Confidence interval [CI]: (0.09; 6.07)). No significant intervention effects were found for time spent on PA, total screen time, dietary habits, and body composition, i.e. body-mass-index and percentage of body fat. CONCLUSIONS: Participation in JolinchenKids - fit and healthy in daycare led to improvements in some indicators for motor skills. However, other health outcomes and behaviours were not affected by program participation over the course of 1 year. TRIAL REGISTRATION: German Clinical Trials Register DRKS00011065 (Date of registration 16-09-2016).

Effectiveness of eHealth interventions for the promotion of physical activity in older adults: A systematic review.

Regular physical activity (PA) is central to healthy ageing. However, only a minority of older adults currently meet the WHO-recommended PA levels. The aim of this systematic review is to compare the effectiveness of eHealth interventions promoting PA in older adults aged 55years and above with either no intervention or a non-eHealth intervention (review registration: PROSPERO CRD42015023875). Eight electronic databases were searched to identify experimental and quasi-experimental studies examining the effectiveness of eHealth interventions for PA promotion in adults aged 55years and above. Two authors independently selected and reviewed references, extracted data, and assessed study quality. In the search, 5771 records were retrieved, 20 studies met all inclusion criteria. Studies varied greatly in intervention mode, content, duration and assessed outcomes. Study quality ranged from poor to moderate. All interventions comprised tailored PA advice and the majority of interventions included goal setting and feedback, as well as PA tracking. Participation in eHealth interventions to promote PA led to increased levels of PA in adults aged 55years and above when compared to no intervention control groups, at least in the short term. However, the results were inconclusive regarding the question of whether eHealth interventions have a greater impact on PA behavior among older adults than non-eHealth interventions (e.g., print interventions). eHealth interventions can effectively promote PA in older adults aged 55years and above in the short-term, while evidence regarding long-term effects and the added benefit of eHealth compared to non-eHealth intervention components is still lacking.

Design and methods for a cluster-controlled trial conducted at sixty-eight daycare facilities evaluating the impact of "JolinchenKids - Fit and Healthy in Daycare", a program for health promotion in 3- to 6-year-old children.

BACKGROUND: The prevention of overweight and obesity during infancy is a highly relevant public health topic given the significant impact of childhood obesity on acute and chronic diseases, general health, and well-being in later stages of life. Apart from the family setting, daycare facilities (DFs) represent a key setting for health promotion among children under the age of six years. "JolinchenKids - Fit and Healthy in Daycare" is a multi-component program promoting physical activity (PA), healthy eating, and mental well-being in 3- to 6-year-old preschoolers at DFs, originally designed by the German health insurance AOK. To evaluate program effectiveness, a cluster-controlled trial involving 68 DFs is currently conducted. The objective of this article is to describe the background, study design, and aims of this trial. METHODS/DESIGN: Sixty-eight DFs across Germany will be recruited to take part in the study, half of them serving as intervention DFs and half of them as delayed intervention control DFs (which receive the program upon completion of the study). At each DF, height, weight, and body composition, as well as motor skills, will be assessed in twenty 3- to 6-year-old children. Children's eating and PA habits, and mental well-being will be assessed via parental questionnaires. A subsample of children (i.e., at 24 DFs which are randomly selected within a geographic region) will be asked to wear accelerometers at their wrists to objectively measure PA over the course of seven days. To compare changes in body composition, motor skills, eating and PA habits, and mental well-being of children at intervention DFs with those observed among children at delayed intervention control DFs over one year, all measurements will take place at baseline and twelve months after the launch of the program at all DFs. DISCUSSION: This study investigates the influence of a health promotion program in the daycare setting on various outcomes, including body composition and objectively measured PA, in a nationwide sample of 3- to 6-year-old preschoolers. This study will provide evidence regarding the effectiveness of a multi-component program for health promotion in this setting and may provide insights into new strategies for preventing obesity in early life. TRIAL REGISTRATION: German Clinical Trials Register DRKS00011065 (Date of registration 16-09-2016).

Development and evaluation of two web-based interventions for the promotion of physical activity in older adults: study protocol for a community-based controlled intervention trial.

BACKGROUND: Regular physical activity (PA) is a key contributor to healthy ageing. However, despite known health benefits, only one third of older adults in Germany reach the PA levels recommended for persons aged 65 years and above by the World Health Organization. The aim of the current study is to evaluate the effectiveness of two web-based interventions for the initiation and maintenance of regular PA (i.e., intervention groups 1 and 2) compared to a delayed intervention control group of older adults aged 65 to 75 years. METHODS/DESIGN: Study participants will be randomly assigned to one of three study arms in five communities in the Bremen-Oldenburg metropolitan region: a) Participants in the first arm will receive access to a web-based intervention for 10 weeks allowing them to track their weekly PA (subjective self-monitoring, intervention group 1); b) participants in the second arm will receive access to the web-based intervention for 10 weeks and, in addition, track PA using Fitbit Zips (objective self-monitoring, intervention group 2); c) participants in the delayed intervention control group will receive access to the intervention implemented in the first study arm after completion of the 12-week follow-up in the other two groups within each community. In addition, weekly group meetings in the communities will be offered to study participants in the intervention groups providing the opportunity to address questions related to the use of the website and to practice PA in groups (e.g., neighborhood walks, strength and balance exercises). To evaluate short-term effects of the intervention on physical and psychological health, PA, physical fitness, and cognitive and psychological variables will be assessed at baseline and 12-week follow-up. DISCUSSION: This study will provide answers regarding acceptance and effectiveness of web-based interventions promoting uptake and maintenance of regular PA in persons aged 65-75 years. Study findings will contribute to a growing body of evidence in Germany concerning the role of community-based interventions for the promotion of PA and healthy ageing in older adults. TRIAL REGISTRATION: German Clinical Trials Register DRKS00010052 (Date of registration 07-11-2016).

Views of policy makers and health promotion professionals on factors facilitating implementation and maintenance of interventions and policies promoting physical activity and healthy eating: results of the DEDIPAC project.

BACKGROUND: The uptake, implementation, and maintenance of effective interventions promoting physical activity (PA) and a healthy diet and the implementation of policies targeting these behaviors are processes not well understood. We aimed to gain a better understanding of what health promotion professionals and policy makers think are important factors facilitating adoption, implementation, and maintenance of multi-level interventions and policies promoting healthy eating and PA in Belgium, Germany, Ireland, Norway, and Poland. METHODS: Six interventions and six policies were identified based on pre-defined criteria. Forty semi-structured interviews were conducted with stakeholders from various sectors to elicit information on factors impacting adoption, implementation, and maintenance of these interventions and policies. All interview transcripts were coded in NVivo, using a common categorization matrix. Coding in the respective countries was done by one researcher and validated by a second researcher. RESULTS: Active involvement of relevant stakeholders and good communication between coordinating organizations were described as important factors contributing to successful adoption and implementation of both interventions and policies. Additional facilitating factors included sufficient training of staff and tailoring of materials to match needs of various target groups. The respondents indicated that maintenance of implemented interventions/policies depended on whether they were embedded in existing or newly created organizational structures in different settings and whether continued funding was secured. CONCLUSIONS: Despite considerable heterogeneity of interventions and health policies in the five countries, stakeholders across these countries identify similar factors facilitating adoption, implementation, and maintenance of these interventions and policies.

Characterizing Active Ingredients of eHealth Interventions Targeting Persons With Poorly Controlled Type 2 Diabetes Mellitus Using the Behavior Change Techniques Taxonomy: Scoping Review.

BACKGROUND: The behavior change technique taxonomy v1 (BCTTv1; Michie and colleagues, 2013) is a comprehensive tool to characterize active ingredients of interventions and includes 93 labels that are hierarchically clustered into 16 hierarchical clusters. OBJECTIVE: The aim of this study was to identify the active ingredients in electronic health (eHealth) interventions targeting patients with poorly controlled type 2 diabetes mellitus (T2DM) and relevant outcomes. METHODS: We conducted a scoping review using the BCTTv1. Randomized controlled trials (RCTs), studies with or pre-post-test designs, and quasi-experimental studies examining efficacy and effectiveness of eHealth interventions for disease management or the promotion of relevant health behaviors were identified by searching PubMed, Web of Science, and PsycINFO. Reviewers independently screened titles and abstracts for eligibility using predetermined eligibility criteria. Data were extracted following a data extraction sheet. The BCTTv1 was used to characterize active ingredients of the interventions reported in the included studies. RESULTS: Of the 1404 unique records screened, 32 studies fulfilled the inclusion criteria and reported results on the efficacy and or or effectiveness of interventions. Of the included 32 studies, 18 (56%) were Web-based interventions delivered via personal digital assistant (PDA), tablet, computer, and/or mobile phones; 7 (22%) were telehealth interventions delivered via landline; 6 (19%) made use of text messaging (short service message, SMS); and 1 employed videoconferencing (3%). Of the 16 hierarchical clusters of the BCTTv1, 11 were identified in interventions included in this review. Of the 93 individual behavior change techniques (BCTs), 31 were identified as active ingredients of the interventions. The most common BCTs identified were instruction on how to perform behavior, adding objects to the environment, information about health consequences, self-monitoring of the outcomes and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided of a certain behavior Author: Please note that the journal discourages the use of parenthesis to denote either and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided "and/or" and prefers to be explicit to avoid ambiguity. Response: Checked and avoided, and feedback on outcomes of behavior. CONCLUSIONS: Our results suggest that the majority of BCTs employed in interventions targeting persons with T2DM revolve around the promotion of self-regulatory behavior to manage the disease or to assist patients in performing health behaviors necessary to prevent further complications of the disease. Detailed reporting of the BCTs included in interventions targeting this population may facilitate the replication and further investigation of such interventions.

[Promoting a balanced diet and physical activity among children : Conditions for the successful implementation and maintenance of multi-level interventions and policies: Results of two qualitative case studies]. / Förderung einer ausgewogenen Ernährung und körperlicher Aktivität von Kindern : Voraussetzungen für eine erfolgreiche Implementierung und Aufrechterhaltung von Mehrebeneninterventionen und politischen Maßnahmen: Ergebnisse aus zwei qualitativen Fallstudien.

BACKGROUND: To date, conditions for successfully implementing and maintaining multi-level interventions and policies for the promotion of a balanced diet and physical activity are not well understood from the perspective of stakeholders. OBJECTIVE: The aim of this article is to examine which factors are regarded as facilitating or impeding introduction, implementation and maintenance of multi-level interventions and policies from the standpoint of stakeholders. MATERIALS AND METHODS: Semi-structured face-to-face interviews with stakeholders of one multi-level intervention (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS [IDEFICS] for the prevention of childhood obesity, n = 4) and one policy (Federal state offices coordinating networks for the provision of healthy food options in schools, n = 3) were analysed using qualitative content analysis. RESULTS: In both cases, the use of existing structures facilitated introduction, implementation and maintenance. Additionally, training of staff for implementation according to standardised protocols or concepts and taking structures and work conditions of settings into account during implementation were considered essential. In both cases, conflicting interests in interdisciplinary stakeholder teams regarding intervention content and implementation were identified as a barrier. A lack of political support and insecure long-term funding only played a role in regard to the implementation and maintenance of policies. On the other hand, target groups of the multi-level intervention were not sufficiently involved in the development of intervention materials which resulted in a lack of tailoring and acceptance in the target groups. CONCLUSIONS: The results provide important insights into the long-term implementation of multi-level interventions and policies in different settings.

Development and evaluation of the efficacy of a web-based 'social norms'-intervention for the prevention and reduction of substance use in a cluster-controlled trial conducted at eight German universities.

BACKGROUND: Previous research suggests that perceptions of peer substance use are associated with personal use. Specifically, overestimating use in the peer group is predictive of higher rates of personal substance use. 'Social norms'-interventions are based on the premise that changing these misperceived social norms regarding substance use by providing feedback on actual norms is associated with a reduction in personal substance use. Studies conducted in the U.S.A. suggest that 'social norms'-feedback is an effective strategy for reducing substance use among university students. It is unknown whether the effects of a 'social norms'-feedback on substance use can be replicated in a sample of German university students. The objective of this article is to describe the study design and aims of the 'INternet-based Social norms-Intervention for the prevention of substance use among Students' (INSIST)-study, a cluster-controlled trial examining the effects of a web-based 'social norms'- intervention in students enrolled at four intervention universities with those enrolled at four delayed intervention control universities. The INSIST-study is funded by the German Federal Ministry of Health. METHODS/DESIGN: Eight universities in four regions in Germany will take part in the study, four serving as intervention and four as delayed intervention control universities (randomly selected within a geographic region). Six hundred students will be recruited at each university and will be asked to complete a web-based survey assessing personal and perceived substance use/attitudes towards substance use at baseline. These data will be used to develop the web-based 'social norms'-feedback tailored to gender and university. Three months after the baseline survey, students at intervention universities will receive the intervention. Two months after the launch of the intervention, students of all eight universities will be asked to complete the follow-up questionnaires to assess changes in perceptions of/attitudes toward peer substance use and rates of personal substance use. DISCUSSION: This study is the first German cluster-controlled trial investigating the influence of a web-based 'social norms'-intervention on perceptions of/attitudes towards substance use and substance use behavior in a large university student sample. This study will provide new information on the efficacy of this intervention strategy in the German university context. TRIAL REGISTRATION: DRKS00007635 at the 'German Clinical Trials Register' (17.12.2014).

Do tanning salons adhere to new legal regulations? Results of a simulated client trial in Germany.

In August 2009 and January 2012, two regulations were passed in Germany to limit UV exposure in the general population. These regulations state that no minors are allowed to use tanning devices. Personnel of tanning salons is mandated to offer counseling regarding individual skin type, to create a dosage plan with the customer and to provide a list describing harmful effects of UV radiation. Furthermore, a poster of warning criteria has to be visible and readable at all times inside the tanning salon. It is unclear whether these regulations are followed by employees of tanning salons in Germany, and we are not aware of any studies examining the implementation of the regulations at individual salons. We performed a simulated client study visiting 20 tanning salons in the city-state of Bremen in the year 2014, using a short checklist of criteria derived from the legal requirements, to evaluate whether legal requirements were followed or not. We found that only 20 % of the tanning salons communicated adverse health effects of UV radiation in visible posters and other materials and that only 60 % of the salons offered the required determination of the skin type to customers. In addition, only 60 % of the salons offered to complete the required dosage plan with their customers. To conclude, our results suggest that the new regulations are insufficiently implemented in Bremen. Additional control mechanisms appear necessary to ensure that consumers are protected from possible carcinogenic effects of excessive UV radiation.

Dimensions of religiousness and cancer screening behaviors among church-going Latinas.

Churches are a promising setting through which to reach Latinas with cancer control efforts. A better understanding of the dimensions of religiousness that impact health behaviors could inform efforts to tailor cancer control programs for this setting. The purpose of this study was to explore relationships between dimensions of religiousness with adherence to cancer screening recommendations among church-going Latinas. Female Spanish-speaking members, aged 18 and older from a Baptist church in Boston, Massachusetts (N = 78), were interviewed about cancer screening behaviors and dimensions of religiousness. We examined adherence to individual cancer screening tests (mammography, Pap test, and colonoscopy), as well as adherence to all screening tests for which participants were age-eligible. Dimensions of religiousness assessed included church participation, religious support, active and passive spiritual health locus of control, and positive and negative religious coping. Results showed that roughly half (46 %) of the sample had not received all of the cancer screening tests for which they were age-eligible. In multivariate analyses, positive religious coping was significantly associated with adherence to all age-appropriate screening (OR = 5.30, p < .01). Additional research is warranted to replicate these results in larger, more representative samples and to examine the extent to which enhancement of religious coping could increase the impact of cancer control interventions for Latinas.

University Students' Financial Situation During COVID-19 and Anxiety and Depressive Symptoms: Results of the COVID-19 German Student Well-Being Study (C19 GSWS).

Background: The COVID-19 pandemic has had a major impact on students' financial situation as well as on their mental health. Aim: To examine the reported change in the financial situation of German university students before and across two time points of the COVID-19 pandemic and to evaluate its associations with anxiety and depressive symptoms. Methods: We used data from the cross-sectional COVID-19 German Student Well-being Study conducted at five German universities (N = 7203). Linear regression models were used to analyze associations between a reported change in financial situation and anxiety and depressive symptoms. Results: Twenty-eight percent of the participants reported to have a worsened financial situation at the time of the survey compared to the time prior to the pandemic. A worsened financial situation at the time of the survey as compared to prior to the pandemic was associated with higher levels of anxiety and depressive symptoms reported in all three depression and anxiety scales [a 1.46 point increase on the CES-D 8 scale (95% confidence interval (CI): 1.19; 1.73), a 0.37-point increase in PHQ-2 (95% CI: 0.28; 0.46), and a 0.45-point increase in GAD-2 (95% CI: 0.35; 0.55)]. An improved financial situation, on the other hand, was associated with lower levels of anxiety and depressive symptoms. As for the second change, comparing the current financial situation with the situation during the first wave of the pandemic, the associations with anxiety and depressive symptoms were broadly similar. Conclusion: Our findings suggest that students are a vulnerable population in need of mental and financial support during times of crisis. Future research is needed to obtain insights into potential long-term effects of the pandemic on students' mental health.

Message formats and their influence on perceived risks of tobacco use: a pilot formative research project in India.

In India, tobacco kills 900,000 people every year though the burden of tobacco is faced disproportionately in poorer states such as Bihar. Teachers may be a particularly influential group in setting norms around tobacco use in the Indian context. However, tobacco use among teachers remains high and perceptions of tobacco-related health risks are unexplored. To qualitatively explore perceptions about tobacco use among teachers in Bihar and to examine how risk information may be communicated through a variety of message formats, 12 messages on tobacco health risks varying in formats were tested in focus groups with teachers from Bihar. Participants stated that teachers were already aware of tobacco-related health risks. To further increase awareness of these risks, the inclusion of evidence-based facts in messages was recommended. Communicating risk information using negative emotions had a great appeal to teachers and was deemed most effective for increasing risk perception. Messages using narratives of teachers' personal accounts of quitting tobacco were deemed effective for increasing knowledge about the benefits of quitting. To conclude, messages using evidence-based information, possibly with negative emotions, testimonials with role models and those messages emphasizing self-efficacy in the format of narratives appear to appeal to teachers in Bihar.